Surgical Knot Tying Manual

Third Edition
Surgical Knot Tying Manual Richard F. Edlich, M.D., Ph.D.
Distinguished Professor of Plastic Surgery,
Third Edition Biomedical Engineering and Emergency Medicine
Founder of DeCamp Burn and Wound Healing Center
University of Virginia Health System
Director of Trauma Prevention, Education and Research
Trauma Specialists, LLP, Legacy Emanuel Hospital
Portland, Oregon
William B. Long III, M.D.
President and Medical Director, Trauma Specialists, LLP,
Legacy Emanuel Hospital
Portland, OR
forward
If this manual heightens only perceptibly students, nurses,
nurse practitioners, physician assistants, surgical residents
and surgeon’s interest in the biology of wound closure and infection,
the long years occupied in my search for improved methods of
wound management would more than fulfill my expectations.
However, another important purpose of this manual is to honor
my colleagues, who collaborated in our clinical and experimental
research investigations. It is a duteous pleasure to acknowledge the
great help that I have received from Dr. George T. Rodeheaver,
Distinguished Research Professor of Plastic Surgery, University of
Virginia Health System and Dr. John G. Thacker, Vice-Chairman
of the Department of Mechanical and Aerospace Engineering,
University of Virginia, who have made numerous scientific
contributions to my studies of wound closure. Dr. Thacker and
Dr. Rodeheaver are excellent teachers who provide the insight and
imagination that solve the most challenging problems. It is also
important to note that studies have been undertaken with gifted
surgeons in Trauma Specialist, LLP who have developed the only
verified Level I Trauma Center in the Pacific Northwest. Dr. William
B. Long III, President and Medical Director of Trauma Specialists,
LLP, of Legacy Emanuel Hospital has played an instrumental role in
evaluating the performance of surgical products for trauma care that
are used throughout the world.

Richard F. Edlich M.D., Ph.D.

table of contents I. Individualized Self-Instruction 1
II. Introduction 2
III. Scientific Basis for Selection of Sutures 4
1. Nonabsorbable Suture 5
2. Absorbable Suture 12
IV. Components of a Knotted Suture Loop using
either a Granny Knot Type or a Square Knot Type 22
V. Mechanical Performance 28
1. Knot Slippage 30
2. Knot Breakage 31
3. Suture Cutting Tissue 32
4. Mechanical Trauma 33
VI. Tying Techniques 34
1. Instrument Tie 37
2. Hand Tie 39
VII. Essential Elements 42
VIII. Two-Hand Techniques 44
1. Square Knot (1=1) 44
2. Surgeon’s Knot Square (2=1) 52
3. Slip Knot (S=S) 62
IX. One-Hand Technique
1. Square (1=1) 70
X. Instrument-Tie Technique
1. Square Knot (1=1) 78
XI. Selection of Suture and Needle Products 86
XII. References 87
 I. individualized self instruction

The root origin of the word education is educare or to anglicize it, edu-care. The meaning
of education, therefore, is to care for, to nourish, to cause to grow. This being their ultimate
responsibility, teachers of surgery should be the most responsive component of the instruction
system. Numerous other pressing clinical and administrative commitments, however, often
limit interactions with the medical students, nurses, nurse practitioners physician assistants,
surgical residents and surgeons. Consequently, learning difficulties may not be identified.
This manual was designed to be a self-instructional teaching aid for the medical student,
resident, and surgeon providing an individualized environment of learning. For convenience,
each page of this manual has wide margins to accommodate personal thoughts and further
clarification. This manual is bound in a ring binder so that it lies flat, a prerequisite for any
knot tying manual. The reader should take as little or as much time as needed to digest the
information and to develop the illustrated psychomotor skills. At the end of this instruction,
you should feel considerably more comfortable in understanding the science of tying surgical
knots. More importantly it is our hope that this manual will inspire, motivate, and encourage
creativity and self-direction in your study of the biology of wound repair and infection.

This Knot Tying Manual is available online at www.covidien.com/syneture.

1
 II. introduction

Through the ages, the tying of knots has played an important role in the life of man.1
Most of the ancient civilized nations, as well as savage tribes, were accomplished
rope makers. Because rope could have served few useful purposes unless it could be
attached to objects by knots, man’s conception of the rope and the knot must have
occurred concomitantly. Knotted ropes played many important roles in the ancient
world, being used in building bridges and in rigging ships.
Because rope and knots have been two of man’s most useful tools since the dawn
of history, it is not surprising that they also have symbolic and even magical
connotations. It was the custom of Roman brides to wear a girdle tied with a square
(reef) knot, which their husbands untied on their marriage night, as an omen of
prolific offspring. Moreover, it was believed that wounds healed more rapidly when
the bandages which bound them were tied with a square (reef) knot.
This mythology of knots may have contributed to some surgeon’s perception of
surgical knots more as an art form, than as a science. For those artisans, the use
of methods and materials for suturing is usually a matter of habit, guesswork, or
tradition.2 This approach to suturing has contributed to a growing concern that
the knot construction employed by many surgeons is not optimal and that they
2
 3. Individualized Self Instruction

use faulty technique in tying knots, which is the weakest link in a tied surgical suture. When
the recommended configuration of a knot, ascertained by mechanical performance tests
was compared to those used by board-certified general surgeons, only 25% of the surgeons
correctly used the appropriate knot construction.3 Of the 25 gynecologists, mostly department
heads, who were polled about their knot tying technique, most were convinced they they
made square knots, even though their knot tying technique resulted in slipknots that became
untied.4 When a knotted suture fails to perform its functions, the consequences may be
disastrous. Massive bleeding may occur when the suture loop surrounding a vessel becomes
untied or breaks. Wound dehiscence or incisional hernia may follow knot disruption.
As with any master surgeon, he/she must understand the tools of his/her profession. The
linkage between a surgeon and surgical equipment is a closed kinematic chain in which
the surgeon’s power is converted into finely coordinated movements that result in wound
closure with the least possible scar and without infection. The ultimate goal of this linkage the
perfection of the surgical discipline. This manual has been written for medical students, nurses,
nurse practitioners physician assistants, surgical residents and surgeons who view themselves
as scientists cultivating and practicing the science of surgery.

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 III. scientific basis for the selection of surgical sutures

There are several different suture materials and needles that provide an accurate
and secure approximation of the wound edges. Ideally, the choice of the suture
material should be based on the biological interaction of the materials employed,
the tissue configuration, and the biomechanical properties of the wound. The
tissue should be held in apposition until the tensile strength of the wound
is sufficient to withstand stress. A common theme of the many reportable
investigations is that all biomaterials placed within the tissue damage the host
defenses and invite infection. Because surgical needles have a proven role in
spreading deadly blood borne viral infection, the surgeon must select surgical
gloves that reduce the risk of accidental injuries during surgery. 5
Important considerations in wound closure are the type of suture, the tying
technique, and the configuration of the suture loops. Selection of a surgical suture
material is based on its biologic interaction with the wound and its mechanical
performance in vivo and in vitro. Measurements of the in vivo degradation of
sutures separate them into two general classes.6 Sutures that undergo rapid
degradation in tissues, losing their tensile strength within 60 days, are considered
absorbable sutures. Those that maintain their tensile strength for longer than

4
60 days are nonabsorbable sutures. This terminology is somewhat misleading because
even some nonabsorbable sutures (i.e., silk, cotton and nylon) lose some tensile
strength during this 60-day interval. Postlethwait7 measured the tensile strength of
implanted nonabsorbable sutures during a period of two years. Silk lost approximately
50% of its tensile strength in one year and had no strength at the end of two years.
Cotton lost 50% of its strength in six months, but still had 30-40% of its original
strength at the end of two years. Nylon lost approximately 25% of its original strength
throughout the two-year observation period.

1. Nonabsorbable surgical sutures

The nonabsorbable sutures of Covidien (formerly Tyco Healthcare, Norwalk, CT)
can be classified according to their origin. Nonabsorbable sutures made from natural
fibers are silk sutures. Sofsilk™ silk sutures are nonabsorbable, sterile, non-mutagenic
surgical sutures composed of natural proteinaceous silk fibers called fibroin. This
protein is derived from the domesticated silkworm species Bombyx mori of the family
bombycidae. The silk fibers are treated to remove the naturally-occurring sericin
gum and braided sutures are available coated uniformly with a special wax mixture

5
 III. scientific basis for the selection of surgical sutures (cont’d)

or silicone to reduce capillarity and to increase surface lubricity which enhances

handling characteristics, ease of passage through tissue, and knot run-down
properties. Sofsilk™ sutures are available colored black with Logwood extract.
Metallic Steel sutures are derived from monofilament stainless steel. Modern
chemistry has developed a variety of synthetic fibers from polyamides
(nylon), polyesters (Dacron™), polyolefins (polyethylene, polypropylene),
polytetrafluoroethylene, to polybutester.
Polypropylene is a linear hydrocarbon polymer that consists of a strand of
polypropylene, a synthetic linear polyolefin. All polypropylenes begin with a base
resin and then go through the following steps: extrusion, drawing, relaxation,
and annealing. Each step in the process will influence the ultimate biomechanical
performance of the suture. Biomechanical studies demonstrate that the
manufacturing process (i.e., annealing, relaxation) can dramatically influence
the surface characteristics without altering its strength. Changes in the surface
characteristics can facilitate knot construction of the suture. Polypropylene
sutures (Surgipro™) that have a low coefficient of friction will facilitate knot
rundown and suture passage through the tissue. A new polypropylene suture
6
(Surgipro™ II) has been developed that has increased resistance to fraying during knot
rundown. Polypropylene sutures are extremely inert in tissue and have been found
to retain tensile strength in tissues for a period as long as two years. Polypropylene
sutures are widely used in plastic, cardiovascular, general, and orthopedic surgery.
They exhibit a lower drag coefficient in tissue than nylon sutures, making them ideal
for use in continuous dermal and percutaneous suture closure.
Monosof™ and Dermalon™ are monofilament sutures composed of the long-chain
polyamide polymers Nylon 6 and Nylon 6.6. They have a high tensile strength
and low tissue reactivity. The pliability characteristics of these sutures permit
good handling. Because nylon sutures are more pliable and easier to handle
than polypropylene sutures, they are favored for the construction of interrupted
percutaneous suture closures. However, polypropylene sutures encounter lower drag
forces in tissue than nylon sutures, accounting for their frequent use in continuous
dermal and percutaneous suture closure. Nylon sutures are also available in a
braided construction. Only nylon sutures are available both as monofilament and
multifilament sutures (Surgilon™). These braided nylon sutures are relatively inert

7
 III. scientific basis for the selection of surgical sutures (cont’d)

in tissue and possess the same handling and knot construction characteristics as
the natural fiber, silk sutures (Sofsilk™).
Polyester sutures (Surgidac™, TiCron™) are comprised of fibers of polyethylene
terephthalate, a synthetic linear polyester derived from the reaction of a glycol
and a dibasic acid. Polyester sutures were the first synthetic braided suture
material shown to last indefinitely in tissues. Their acceptance in surgery was
initially limited because the suture had a high coefficient of friction that interfered
with passage through tissue and with the construction of a knot. When the
sutures were coated with a lubricant, polyester sutures gained wide acceptance in
surgery. This coating markedly reduced the suture’s coefficient of friction, thereby
facilitating knot construction and passage through tissue. The TiCron™ polyester
sutures are coated with silicone, while the surface lubricant for Surgidac™ is
polybutylene adipate. Because some surgeons prefer to tie sutures with a high
coefficient of friction, the Surgidac™ sutures are also available without a surface
coating.
The polybutester suture (Novafil™) is a block copolymer that contains butylene
terephthalate (84%) and polytetramethylene ether glycol terephthalate (16%).
8
Polybutester suture has unique performance characteristics that may be advantageous
for wound closure.8 This monofilament synthetic nonabsorbable suture exhibits
distinct differences in elongation compared with other sutures. With the polybutester
suture, low forces yield significantly greater elongation than that of the other sutures.
In addition, its elasticity is superior to that of other sutures, allowing the suture to
return to its original length once the load is removed. In a study by Trimbos et al.9
they compared the cosmetic outcome of lower midline laparotomy scars using either
nylon or polybutester suture for skin closure. A randomized clinical trial compared
polybutester skin suture with that of nylon for lower midline laparotomy wounds in
50 women undergoing gynecologic surgery. Scar hypertrophy, scar width, scar color,
the presence of cross-hatching marks, and a total score was assessed in all patients at
18 months following surgery and compared by nonparametric statistical tests. The
wounds closed with polybutester suture were significantly less hypertrophic than
those closed with nylon. Regardless of the suture material used, the lower part of
the laparo-tomy scar showed an inferior cosmetic result compared with the upper
part underneath the umbilicus for scar hypertrophy, scar width, and the total scar
score. The surgeons concluded that polybutester skin suture diminished the risk of

9
 III. scientific basis for the selection of surgical sutures (cont’d)

hypertrophic scar formation because of its special properties allowing it to adapt

to changing tensions in the wound. Increased closure tension of the skin in the
midline region above the pubic bone may be caused by a relative immobility of
the skin. In 1997, Pinheiro et al.10 compared the performance of polybutester
sutures to that of nylon sutures in 70 male and female rats in which they
examined the clinical response of the skin in abdominal wall muscle to the use
of these sutures. Under general anesthesia, standard wounds were created in the
dorsum and abdomen of the animals and subjected to suture closure with either
polybutester or nylon. The animals were sacrificed immediately, 12, 24, and 72
hours and at four, five and seven days to evaluate the impact of the sutures on
the wounds. They found that polybutester produced some advantages such as
strength, lack of package memory, elasticity, and flexibility which made suturing
quicker and easier. They concluded that Novafil™ suture can be used safely on
skin and mucosal wounds because it is less irritating to tissues than nylon.
The clinical performance of polybutester suture has been enhanced by coating its
surface with a unique absorbable polymer (Vascufil™).11 The coating is a poly-
tribolate polymer that is composed of three compounds: gylcolide, e-caprolactone,

10
and poloxamer 188. Coating the polybutester suture markedly reduces its drag forces
in musculoaponeurotic, colonic, and vascular tissue. Knot security with the Vascufil™
suture was achieved with only one more throw than with comparably sized, uncoated
polybutester sutures. On the basis of the results of our investigations, coating the
polybutester suture represents another major advance in surgical suture performance.

2. Absorbable surgical sutures

The absorbable sutures of Covidien are made from either collagen or synthetic
polymers. The collagen sutures are derived from the serosal layer of bovine small
intestine (gut). This collagenous tissue is treated with an aldehyde solution, which
cross-links and strengthens the suture and makes it more resistant to enzymatic
degradation. Suture materials treated in this way are called plain gut (Plain Gut). If
the suture is additionally treated with chromium trioxide, it becomes chromic gut
(Chromic Gut), which is more highly cross-linked than plain gut and more resistant
to absorption. When this treatment of collagen sutures is limited, the result is a special
form of chromic gut (Mild Gut) that is more susceptible to tissue absorption. The
plain gut and chromic gut sutures are composed of several plies that have been twisted

11
 III. scientific basis for the selection of surgical sutures (cont’d)

slightly, machine ground, and polished, yielding a relatively smooth surface that
is monofilament-like in appearance. Salthouse and colleagues12 demonstrated
that the mechanism by which gut reabsorbs is the result of sequential attacks
by lysosomal enzymes. In most locations, this degradation is started by acid
phosphatase, with leucine aminopeptidase playing a more important role later in
the absorption period. Collagenase is also thought to contribute to the enzymatic
degradation of these collagen sutures.
Natural fiber absorbable sutures have several distinct disadvantages. First,
these natural fiber absorbable sutures have a tendency to fray during knot
construction. Second, there is considerably more variability in their retention of
tensile strength than is found with the synthetic absorbable sutures. A search for
a synthetic substitute for collagen sutures began in the 1960s. Soon procedures
were perfected for the synthesis of high molecular weight polyglycolic acid, which
led to the development of the polyglycolic acid sutures (Dexon™ II, Dexon™ S).13
These sutures are produced from the homopolymer, polyglycolic acid. Because
of the inherent rigidity of this homopolymer, monofilament sutures produced
from polyglycolic acid sutures are too stiff for surgical use. This homopolymer

12
can be used as a monofilament suture only in the finest size. Consequently, this high
molecular weight homo-polymer is extruded into thin filaments and braided.13 The
thin filaments of Dexon™ II are coated with Polycaprolate™, a copolymer of glycolide
and epsilon-caprolactone, to reduce the coefficient of friction encountered in knot
construction. Dexon™ S is an uncoated braided suture. The polyglycolic acid sutures
(Dexon™ II, Dexon™ S) degrade in an aqueous environment through hydrolysis of the
ester linkage.
Copolymers of glycolide and lactide were then synthesized to produce a Lactomer™
copolymer that is used to produce a new braided absorbable suture (Polysorb™). The
glycolide and lactide behaved differently when exposed to tissue hydrolysis. Glycolide
provides for high initial tensile strength, but hydrolyses rapidly in tissue.13 Lactide
has a slower and controlled rate of hydrolysis, or tensile strength loss, and provides
for prolonged tensile strength in tissue.13
The Lactomer™ copolymer consists of glycolide and lactide in a 9:1 ratio.
The handling characteristics of the Polysorb™ sutures were found to be superior to
those of the Polyglactin 910™ suture.14 Using comparable knot construction and

13
 III. scientific basis for the selection of surgical sutures (cont’d)

suture sizes, the knot breaking strength for Polysorb™ sutures was significantly
greater than that encountered by Polyglactin 910™ sutures. In addition, the mean
maximum knot rundown force encountered with the Polysorb™ sutures was
significantly lower than that noted with the Polyglactin 910™ sutures, facilitating
knot construction.
The surfaces of the Polysorb™ sutures have been coated to decrease their
coefficient of friction.14 The new Polysorb™ suture is coated with an absorbable
mixture of caprolactone/glycolide copolymer and calcium steraroyl lactylate. At
14 days post-implantation, nearly 80% of the USP (United States Pharmacopoeia)
tensile strength of these braided sutures remains. Approximately 30% of their
USP tensile strength is retained at 21 days. Absorption is essentially complete
between days 56 and 70.
We recently studied the determinants of suture extrusion following subcuticular
closure by synthetic braided absorbable sutures in dermal skin wounds.15
Miniature swine were used to develop a model for studying suture extrusion.
Standard, full-thickness skin incisions were made on each leg and the abdomen.

14
The wounds were closed with size 4/0 Polysorb™ or Coated Vicryl™ (Ethicon, Inc.,
Somerville, NJ) sutures. Each incision was closed with five interrupted, subcuticular,
vertical loops secured with a surgeon’s knot. The loops were secured with 3-throw
knots in one pig, 4-throw knots in the second pig, and 5-throw knots in the third pig.
The swine model reproduced the human clinical experience and suture extrusion,
wound dehiscence, stitch abscess, and granuloma formation were all observed. The
cumulative incidence of suture extrusion over 5 weeks ranged from 10 to 33%. Coated
Vicryl™ sutures had a higher mean cumulative incidence of suture extrusion than that
of Polysorb™ sutures (31% vs. 19%). With Polysorb™ sutures, the 5-throw surgeon’s
knots had a higher cumulative incidence of suture extrusion than the 3-throw or 4-
throw surgeon’s knot square, 30% vs. 17% and 10%, respectively. This swine model
offers an opportunity to study the parameters that influence suture extrusion. Because
the volume of suture material in the wound is obviously a critical determinant of suture
extrusion, it is imperative that the surgeon construct a knot that fails by breakage,
rather than by slippage with the least number of throws. Because both braided
absorbable suture materials are constructed with a secure surgical knot that fails only
by breakage rather than slippage with a 3-throw surgeon’s knot square (2 =1 = 1), the

15
 III. scientific basis for the selection of surgical sutures (cont’d)

construction of additional throws with these sutures does not enhance the suture
holding capacity, but plays a key factor in precipitating suture extrusion. Finally,
it is important to emphasize that the surgeon must always construct symmetrical
surgical knots for dermal subcuticular skin closure in which the constructed knot
is always positioned perpendicular to the linear wound incision. Asymmetrical
knot construction for dermal wound closure becomes an obvious invitation for
suture extrusion.
A monofilament absorbable suture (Maxon™) has been developed using
trimethylene carbonate.16 Glycolide trimethylene carbonate is a linear copolymer
made by reacting trimethylene carbonate and glycolide with diethylene glycol
as an initiator and stannous chloride dihydrate as the catalyst. The strength of
the monofilament synthetic absorbable suture, glycolide trimethylene carbonate
(Maxon™), is maintained in vivo much longer than that of the braided synthetic
absorbable suture. This monofilament suture retained approximately 50% of its
breaking strength after implantation for 28 days, and still retained 25% of its
original strength at 42 days. In contrast, braided absorbable sutures retained only
1% to 5% of their strength at 28 days. Absorption of the trimethylene carbonate

16
suture is minimal until about the 60th day post-implantation and essentially complete
within six months.
Another innovation in the development of monofilament synthetic absorbable sutures
has been the production of Glycomer 631, a terpolymer composed of glycolide
(60%), trimethylene carbonate (26%), and dioxanone (14%) (Biosyn™). The Biosyn™
suture has many distinct advantages over the braided synthetic absorbable sutures.17
First, this monofilament suture is significantly stronger than the braided synthetic
absorbable suture over four weeks of implantation. It maintains approximately
75% of its USP tensile strength at two weeks and 40% at three weeks post-
implant. Absorption is complete between 90 to 110 days. Due to it’s construction,
Monofilament suture potentiates less bacterial infection than does the braided suture.
The handling characteristic of this monofilament suture is superior to the braided
suture because it encounters lower drag forces in the tissue than does the braided
suture.
The latest innovation in the development of monofilament absorbable sutures has
been the rapidly absorbing Caprosyn™ suture. Caprosyn™ monofilament synthetic

17
 III. scientific basis for the selection of surgical sutures (cont’d)

absorbable sutures are prepared from Polyglytone™ 6211 synthetic polyester

which is composed of glycolide, caprolactone, trimethylene carbonate, and
lactide. Implantation studies in animals indicate that Caprosyn™ suture retains
a minimum of 50-60% USP knot strength at five days post implantation, and
a minimum of 20-30% of knot strength at 10 days post implantation. All of its
tensile strength is essentially lost by 21 days post implantation.
We recently have compared the biomechanical performance of Caprosyn™
suture to that of Chromic Gut suture.18 The biomechanical performance studies
included quantitative measurements of wound security, strength loss, mass loss,
potentiation of infection, tissue drag, knot security, knot rundown, as well as
suture stiffness. Both Caprosyn™ and Chromic Gut sutures provided comparable
resistance to wound disruption. Prior to implantation, suture loops of Caprosyn™
had a significantly greater mean breaking strength than suture loops of Chromic
Gut. Three weeks after implantation of these absorbable suture loops, the sutures
had no appreciable strength. The rate of loss of suture mass of these two sutures
was similar. As expected, Chromic Gut sutures potentiated significantly more
infection than did the Caprosyn™ sutures.

18
The handling properties of the Caprosyn™ sutures were far superior to those of the
Chromic Gut sutures. The smooth surface of the Caprosyn™ sutures encountered
lower drag forces than did the Chromic Gut sutures. Furthermore, it was much easier
to reposition the Caprosyn™ knotted sutures than the knotted Chromic Gut sutures.
In the case of Chromic Gut sutures, it was not possible to reposition a two-throw
granny knot. These biomechanical performance studies demonstrated the superior
performance of synthetic Caprosyn™ sutures compared to Chromic Gut sutures and
provide compelling evidence of why Caprosyn™ sutures are an excellent alternative to
Chromic Gut sutures.
The direct correlation of molecular weight and breaking strength of the synthetic
absorbable sutures with both in vivo and in vitro incubation implies a similar
mechanism of degradation. Because in vitro incubation provides only a buffered
aqueous environment, the chemical degradation of these sutures appears to be
by non-enzymatic hydrolysis of the ester bonds. Hydrolysis would be expected
to proceed until small, soluble products are formed, then dissolved, and removed
from the implant site. In contrast, the gut or collagen suture, being a proteinaceous
substance, is degraded primarily by the action of proteolytic enzymes.

19
 III. scientific basis for the selection of surgical sutures (cont’d)

A distinction must be made between the rate of absorption and the rate of tensile
strength loss of the suture material. The terms rate of absorption and rate of
tensile strength loss are not interchangeable. Although the rate of absorption is
of some importance with regard to late suture complications, such as sinus tracts
and granulomas, the rate of tensile strength loss is of much greater importance
to the surgeon considering the primary function of the suture, maintaining tissue
approximation during healing.
When considering an absorbable suture’s tensile strength in vivo, we recommend
that the manufacturer provide specific measurements of its holding capacity,
rather than the percentage retained of its initial tensile strength. The United
States Pharmacopoeia (USP) has set tensile strength standards for synthetic
absorbable suture material. If the manufacturers were to use these standards to
describe maintenance of tensile strength, the surgeon would have a valid clinical
perspective to judge suture performance. Some manufacturers persist in reporting
maintenance of the tensile strength of their suture in tissue by referring only to
the percentage retained of its initial tensile strength, making comparisons between

20
sutures difficult. The need to use USP standards in reporting is particularly important
when there are marked differences in the initial tensile strengths of the synthetic
sutures. For example, the initial tensile strength of Biosyn™ is 43% stronger than that
of polydioxanone. At two weeks, the Biosyn™ suture is approximately 30% stronger.

21
 IV. components of a knotted suture loop using either
a granny knot type or a square knot type

The mode of operation of a suture is the creation of a loop

of fixed perimeter secured in the geometry by a knot.19
A tied suture has three components (Figure 1). First, the
loop created by the knot maintains the approximation of
the divided wound edges. Second, the knot is composed of
a number of throws snugged against each other. A throw
is a wrapping or weaving of two strands. Finally, the “ears”
act as insurance that the loop will not become untied
because of knot slippage. The doctor’s side of the knot is
defined as the side of the knot with “ears,” or the side to
which tension is applied during tying. The patient’s side is
the portion of the knot adjacent to the loop.

Figure 1. The components of a tied suture.

22
 Each throw within a knot can either be a single or double throw. A single
throw is formed by wrapping the two strands around each other so that the
angle of the wrap equals 360°. In a double throw, the free end of a strand
is passed twice, instead of once, around the other strand; the angle of this
double-wrap throw is 720°. The tying of one or more additional throws
completes the knot. The configuration of the knot can be classified into
two general types by the relationship between the knot “ears” and the loop
(Figure 2). When the right “ear” and the loop of the two throws exit on the
same side of the knot or parallel to each other, the type of knot is judged to
be square (reef). The knot is considered a granny type if the right “ear” and
the loop exit or cross different sides of the knot.
When the knot is constructed by an initial double-wrap throw followed by
a single throw, it is called a surgeon’s (friction) knot. The configuration of a
reversed surgeon’s knot is a single throw followed by a double-wrap throw.
A knot consisting of two double-wrap throws is appropriately called a
double-double.

Figure 2. The configuration of surgical knots.

23
 IV. components of a knotted suture loop (cont’d)

When forming the first throw of either a square

or granny knot, the surgeon is merely wrapping
one suture end (360°) around the other, with
the suture ends exiting in opposite directions.
The surgeon will apply equal and opposing
tension to the suture ends in the same planes.
The direction of the applied tensions will be
determined by the orientation of the suture
loop in relation to that of the surgeon’s hands.
When the surgeon’s hands lie on each side and
parallel to the suture loop, the surgeon will
apply tensions in a direction parallel to his/her
forearms. (Figure 3).

Figure 3. During knot construction, the

surgeon’s hands should be on each side
and parallel to the suture loop

24
Tension will be applied to the farther suture end in a
direction away from the surgeon. Conversely, and equal
opposing force will be applied to the closer suture end in
a direction toward the surgeon. After constructing
the second throw of these knots, the direction of the
suture ends must be reversed, with an accompanying
reversal of the position of the surgeon’s hand. As the
surgeon’s hands move toward or away from his body,
the movements of his right and left hands are in
separate and distinct areas that do not cross, permitting
continuous visualization of knot construction. With each
additional throw, the surgeon must reverse the position
of his/her hands.
Orientation of the suture loop in a plane that is
perpendicular to that of the surgeon’s forearms
considerably complicates knot construction (Figure 4).
In this circumstance, reversal of the position of the hands
occurs in the same area, with crossing and overlapping Figure 4. The surgeon’s hands frequently
of the surgeon’s hands, temporarily obscuring overlap (arrows) when the orientation of
visualization of knot construction. This circumstance the hands is perpendicular to that of the
suture loop.
may be encountered when constructing knots in a
deep body cavity, which considerably limits changes
in hand positions. This relatively cumbersome hand
position may interfere with the application of uniform
opposing tensions to the suture ends, an invitation to the
conversion of a square knot construction to a slip knot.

25
 IV. components of a knotted suture loop (cont’d)

The granny knot and square knot can

become a slip knot by making minor
changes in the knot tying technique
(Figure 5). Surgeons who do not reverse
the position of their hands after forming
each throw will construct slip knots.
Furthermore, the application of greater
tension to one ”ear” than the other
encourages construction of slip knots, a
practice commonly encountered in tying
deep-seated ligatures.20

Figure 5. When the tension (arrow)

is reapplied in equal and opposing
directions, the slip knot can be
converted into a square knot.

26
When the tension is reapplied in equal and opposing directions, the slip knots can
usually be converted into either the square or granny knots. A simple code has been
devised to describe a knot’s configuration (Figure 2).21 The number of wraps for
each throw is indicated by the appropriate Arabic number. The relationship between
each throw being either crossed or parallel is signified by the symbols X or =,
respectively. In accordance with this code, the square knot is designated 1=1,
and the granny knot 1x1. The presence of a slip knot construction is indicated by
the letter S. This method of describing knots facilitates their identification and
reproduction. It is, for example, perfectly obvious what is meant by 2x2x2, without
giving the knot a name, and all surgical knots can be defined unequivocally in this
international language.
Sutures remain the most common method of approximating the divided edges of
skin. Skin closure can be achieved by either percutaneous suture closure, dermal
suture closure, or a combination of both techniques. Dermal or percutaneous suture
closures are accomplished by either interrupted suture or a continuous suture
closure technique.
When utilizing a continuous suture, the first suture loop is constructed by using
the single strand of the fixed suture end attached to the needle and a single strand
of the free suture end. However, the knot of the last suture loop at the end of the
continuous suture is constructed by a suture loop containing two strands and the
single strand of the fixed suture end attached to the needle.

27
 IV. components of a knotted suture loop (cont’d)
Figure 6. Construction of a square knot with
two single strands.
Figure 7. Construction of a square knot with
a single strand and suture loop.
28
The first knot in a percutaneous and dermal suture closure
usually has a square knot construction. A tied square knot suture
has three components (Figure 6). The loop created by the knot
maintains the apposition of tissue. The knot is composed of a
number of throws secured against each other. The ears are the cut
ends of the suture, which add security to the knot by preventing
untying during slippage.
At the end of a percutaneous and dermal closure, te knot must
be constructed as a square knot with a single strand and a suture
loop. A square knot of an interrupted suture loop is formed by
two single throws in which the right ear and loop come out in a
position that is directly opposite to that of the left ear and loop.
The configuration of a knot using a looped suture end and a fixed
suture end attached to a needle is markedly different from the
interrupted knotted suture loop in which knot construction is
accomplished by two separate strands of sutures. The interrupted
suture has a knot constructed by two single strands. In contrast,
knots constructed with a suture loop have two suture strands that
are intertwined with the single strand of the fixed suture end. When knot construction
is complete, the interrupted percutaneous suture has two cut suture ends. Knots
constructed by a double-strand suture loop and a single strand of the fixed suture end
has three separate knot ears (Figure 7). The square knot is formed when the right ear
and the loop of a two-throw knot exit on the same side of the knot and are parallel to
each other.
During wound closure, knot construction involves two steps. The first secures precise
approximation of the wound edges by advancing either a one-throw or a two-throw
knot to the wound surface. The second step is the construction of additional throws
until knot security is attained and slippage is prevented.22
Our biomechanical performance studies demonstrate that secure knot configuration
of the interrupted suture loop created at the beginning of the wound is quite
different from secure knot configuration of the knot constructed at the end of the
wound. These differences in secure knot configurations are related to the types of
suture strands used in knot construction. The first knot in a continuous suture is
constructed by two single strands, and the second knot is created by a single strand
and a suture loop. Knot construction with a suture loop predisposes the knot to suture
slippage and requires additional throws for knot security. When constructing the
first interrupted suture loop with either absorbable or nonabsorbable monofilament
sutures, knot security is achieved with square knot construction by using three or four
throws. The last suture loop and single strand involves at least five or six throws for
knot security. If the trauma surgeon fails to construct secure knots at the beginning or
the end of the laceration, knot slippage will occur, resulting in wound dehiscence.

29
 V. mechanical performance

The mechanical performance of a suture is an important consideration

in the selection of a surgical suture and can be measured by reproducible,
biomechanical parameters.23 The suture’s stiffness reflects its resistance
to bending. Its coefficient of friction is a measure of the resistive forces
encountered by contact of the surfaces of the suture material during knot
construction. Strength is a key performance parameter that indicates the
suture’s resistance to breakage. The knot breakage load for a secure knot that
fails by breakage is a reliable measure of strength. During these tests, forces
are applied to the divided ends of the suture loop, the patient’s side of the
knot. As the suture is subjected to stress, it will elongate. The load elongation
properties of a suture have important clinical implications. Ideally, the
suture should elongate under low loads to accommodate for the developing
wound edema, but return to its original length after resolution of the edema.
Although it should exhibit an immediate stretch under low loads, it should
not elongate any further while continuously maintaining the load, exhibiting
a resistance to creep.
These biomechanical parameters play important roles in the clinical
performance of the suture.24 Surgeons consider the handling characteristics
of the suture to be one of the most important parameters in their selection
of sutures. Surgeons evaluate the handling characteristics of sutures by
constructing knots using manual and instrument-tie techniques. The
surgeon prefers a suture which permits two-throw knots to be easily
advanced to the wound edges, providing a preview of the ultimate
30
apposition of the wound edges. The force required to advance the knot is called
knot rundown force. Once meticulous approximation of the wound edges is
achieved, the surgeon prefers to add one more throw to the two-throw knot so
that it does not fail by slippage.
The magnitude of the knot rundown force is influenced considerably by the
configuration of two-throw knots. 24 Knot rundown of the surgeon’s knot
square (2=1) generates sufficient forces to break the knot. In contrast, knot
rundown of square (1=1), granny (1x1) and slip (S=S, SxS) knots occurs by
slippage. For comparable sutures, the mean knot rundown force for square knots
is the greatest, followed by that for the granny (1x1) knots, and then the slip
(S=S, SxS) knots.
Failure of the knotted suture loop may be the result of either knot slippage or
breakage, suture cutting through tissues, and mechanical crushing of the suture
by surgical instruments. Initially, the knotted suture fails by slippage, which
results in untying of the knot. All knots slip to some degree regardless of the
type of suture material. When slippage is encountered, the cut ends (“ears”) of
the knot must provide the additional material to compensate for the enlarged
suture loop. When the amount of knot slippage exceeds the length of the cut
“ears,” the throws of the knot become untied. In general, surgeons recommend
that the length of the knot ”ears” be 3mm to accommodate for any knot slippage.
3 Dermal sutures are, however, an exception to this rule. Because the “ears” of
dermal suture knots may protrude through the divided skin edges, surgeons
prefer to cut their dermal suture “ears” as they exit from the knot. It must be
emphasized that knot security is achieved in a knot with “ears”with one more
throw than in a comparable knot whose “ear” length is 3mm.

31
 knot slippage Knot slippage is counteracted by the frictional forces of the knots. The
degree to which a knot slips can be influenced by a variety of factors
including the coefficient of friction of the suture material, suture diameter,
moisture, knot type and final geometry. Knots of the granny type (crossed)
usually exhibit more slippage than do knots with a square-type (parallel)
construction.
With each additional throw, incrementally greater forces are required for
knot untying. After a specified number of throws, failure will occur by knot
breakage, after which the knot breakage force will not be enhanced by the
addition of more throws. Consequently, these additional throws offer no
mechanical advantage and represent more foreign bodies in the wound that
damage host defenses and resistance to infection.
The human element in knot tying has considerable influence on the
magnitude of knot slippage.19 The amount of tension exerted by the
surgeon on the “ears” of the knot significantly alters the degree of slippage.
The careless surgeon who applies minimal tension (10% of knot break
strength) to the “ears” of the knot constructs knots that fail by slippage.
Knot slippage can be minimized by applying more tensions (80% of knot
break strength) to the “ears” of the knot. Another serious error often made
by the inexperienced surgeon is not to change the position of his/her hands
appropriately during construction of square and/or granny type knots. The
resulting knot, a sliding or slip knot, will become untied regardless of the
suture material. The risk of forming a slip knot is greatest when tying one-
hand knots and/or with deep seated ligatures.20-23

32
When enough force is applied to the tied suture to result in breakage, the site of
disruption of the suture is almost always the knot. The force necessary to break
knot breakage
a knotted suture is lower than that required to break an untied suture made
of the same material.19 The forces exerted on a tied suture are converted into
shear forces, by the knot configuration that break the knot. The percentage loss
of tensile strength, as a result of tying a secure knot, is least with mono-filament
and multifilament steel.25 This relationship between the tensile strength of
unknotted and knotted suture which is designated knot efficiency, is described
in the following equation:
Knot efficiency (%) = tensile strength of a knotted suture
tensile strength of unknotted suture
Regardless of the type of suture material, the efficiency of the knot is enhanced
with an increasing number of throws, although only up to a certain limit.
The type of knot configuration that results in a secure knot that fails by
breaking varies considerably with different suture material. The magnitude of
force necessary to produce knot breakage is influenced by the configuration
of the knotted suture loop, type of suture material, and the diameter of the
suture.3 The tissue in which the suture is implanted also has considerable
influence on the knot strength of suture. In the case of absorbable sutures, a
progressive decline in knot breaking strength is noted after tissue implantation.
In addition, the magnitude of knot breakage force is significantly influenced by
the rate of application of forces to the “ears” of the knot.23 When a constant
force is applied slowly to the knot “ears,” the knot breakage force is significantly
greater than that for knots in which the same constant force is applied rapidly
to the “ears.” The latter knot loading rate is often referred to as “the jerk at the
end of the knot,” especially when the knotted suture breaks.
33
 suture cutting Suture failure also may occur if the knotted suture loop cuts through the
tissue. The type of tissue has considerable influence on the magnitude of
tissue force required to tear the suture through the tissue. Howes and Harvey26
reported that the forces required to tear gut sutures through canine
fascia was the greatest followed by muscle, peritoneum and then fat.
Using cadaver specimens 6 to 93 days after death, Tera and °Aberg27
measured the magnitude of forces required for suture to tear through
excised musculoaponeurotic layers of laparotomy incisions. The rationale
for this study was that the forces required to tear sutures through a
musculoaponeurotic layer would provide a basis for the choice of a
suture whose strength is at least as strong as the forces required to tear
the suture through the tissue. When the suture was passed lateral to the
transition between the linea alba and the rectus sheath, the force required
to tear the suture through the tissue was greater than that for any other
musculoaponeurotic layer tested; the paramedian incision required the
lowest forces to pull sutures through its sheaths. When they recorded the
forces needed for sutures to tear through structures involved in the repair of
inguinal hernia, the structures making up the conjoined tendon and Cooper’s
ligament were the strongest and exhibited twice the resistance to suture
tearing than those of the other structures.
As expected, the force required for sutures to tear through tissue changes
during healing. Aberg28 reported that the forces needed for sutures to tear
through the aponeurotic muscle layer reduced significantly during the first
week of healing. When the wound edges were approximated by suture tied
tightly around this aponeurotic muscle layer, the reduction in force needed
for the suture to pull through this tissue persisted for two weeks.
34
Mechanical trauma to the suture by surgical instruments can also result in
suture failure. Nichols et al29 cautioned surgeons about the handling of
mechanical trauma
sutures by surgical instruments. They indicated that either the application of
clamps and forceps to the suture or rough handling of sutures could damage
and weaken them. Stamp et al30 incriminated the teeth in the needle holder
jaws as important causal factors of sutural damage. Compression of sutures
between the needle holder jaws with teeth produced morphologic changes in
sutures that resulted in a marked reduction in the suture breaking strength.
Similarly, the sharp edges of needle holder jaws without teeth can even crush
the suture and, thereby, decrease its strength.31 Finally application of large
compressive loads by pinching polypropylene sutures with DeBakey forceps
decreases the strength of the suture.32

35
 VI. tying techniques

The surgeon may use an individual ligature (“free tie”) or a suture that is attached
to a needle or ligature reel. The length of a free tie or suture attached to a needle is
usually 18 inches. The longest strands of suture material are available on a reel or
spool. When the suture is attached to a needle or reel, there is a free end and a fixed
end; the fixed end is attached to either the needle or reel. The first throw of a knot
is accomplished by wrapping the free end either once or twice (surgeon’s) around
the fixed end. During practice, clamp one end of the suture with an instrument that
serves to represent either the needle or the reel, which is the fixed end of the suture.
Formation of each throw of a knot is accomplished in three steps. The first step
is the formation of a suture loop. In the second step, the free suture end is passed
through the suture loop to create a throw. The final step is to advance the throw
to the wound surface. For the first throw of a square, granny, and surgeon’s knot
square, for each additional throw the direction in which tension is applied to the
suture ends is reversed. The surgeon should construct a knot by carefully snugging
each throw tightly against another. The rate of applying tension to each throw
should be relatively slow.
For either the square knot or surgeon’s knot square, the direction in which the
free suture end is passed through the loop will be reversed for each additional
throw. If the free suture end is passed down through the first suture loop, it must
be passed up through the next suture loop. Reversal of the direction of passage of
the free suture end through the loops does not alter either the knot’s mechanical
performance or its configuration. It simply reverses the presentation of the knot
(Figure 8). For granny knots, the direction in which the free suture end is passed
36 through the loop is the same for each additional throw.
 Figure 8. Square knot (1=1) (A) is formed by first
passing the free suture end up through the suture
loop to create the first throw. The second throw
is formed by passing the free suture end down
through the suture loop. Square knot (1=1) (B)
is formed by passing the free suture end down
through the suture loop to create the first throw.
The second throw is formed by passing the free
suture end up through the suture loop.

During surgery, knot construction involves two distinct steps. The

purpose of the first step is to secure precise approximation of the
wound edges by advancing either a one-throw or a two-throw knot to
the wound surface. Once the throw or throws contact the wound, the
surgeon will have a preview of the ultimate apposition of the wound
edges. Ideally, the knotted suture loop should reapproximate the
divided wound edges without strangulating the tissue encircled by the
suture loop. If there is some separation of the wound edges, the one-
throw or two-throw knot can be advanced to reduce the size of the
suture loop and thereby bring the wound edges closer together.
When the surgeon forms a double-wrap throw, the first throw of the
surgeon’s knot square (2=1) can maintain apposition of the wound
edged by “locking” or temporarily securing it in place by reversing
the direction of pull on its “ears.” The “locked” double throw is not
37
 VI. tying techniques (cont’d)

a reliable means of maintaining wound apposition because any tension applied to the
“ears” from the patient’s side of the knot will unlock the knot. The addition of the
second throw to the surgeon’s knot square (2=1) will provide additional resistance to
wound disruption, but this knot will not advance by slippage, limiting the surgeon’s
ability to secure meticulous coaptation of the wound edges.24
In contrast, two-throw square (1=1) or granny (1x1) knots can be advanced to the
wound surface to secure precise wound edge apposition. These two-throw square
(1=1) or granny (1x1) knots can be easily converted into their respective slip knots by
applying tension to only one “ear” in a direction that is perpendicular to that of the
tissue surface. Square (S=S) or granny (SxS) slip knots require lower knot rundown
force for knot advancement than either the square (1=1) or granny (1x1) knots, but
will never reach knot security even with 5 throws. 9 The risk of tying slip knots can
be obviated by applying tensions to both “ears” in horizontal planes parallel to the
tissue surface. The second step in knot construction is the addition of a sufficient
number of throws to the knot so that it does not fail by slippage. The magnitude of
knot breakage force is always greater than that for knot slippage force of a comparable
suture, ensuring optimal protection against wound dehiscence. The magnitude of knot
breakage force is significantly influenced by the rate of application of forces to the
knot. When constant force is applied slowly to the knot “ears,” the knot breakage force
is significantly greater than that for knots in which the same constant force is applied
rapidly to the “ears.”

38
 instrument tie

Knot construction can be accomplished by either an instrument or hand tie. An

instrument tie occurs by the formation of suture loop over an instrument, usually
a needle holder. The right hand holds the needle holder, while the left hand loops
the fixed suture end around the instrument. The position of the instrument in
relation to the suture ends during knot construction will determine the type of
knot. When the instrument is placed above the fixed suture end during the first and
second throws, a square-type knot will develop. In contrast, a granny-type knot will
first result when the instrument is placed above the fixed suture end for the first
throw and then below the fixed suture end for the second throw. By repeating this
positioning, the instrument tie is a reliable and easy method to produce multiple
throw granny knots (1x1x1), a circumstance not encountered in hand ties. Granny
knots with more than two throws cannot be constructed by either the one-hand or
two-hand technique, without releasing hold of both suture ends.
Instrument tying is accomplished primarily by the surgeon’s left hand, which holds
the fixed suture end. Initially the length of the fixed suture end held by the left hand
is long (17 in.), making it difficult to form knots without injuring the attending
assistant. This assault can be avoided by shortening the length of the fixed suture
end held by the left hand. Preferably, the fixed suture end should be coiled into
loops, which are held between the tips of the thumb and index finger.

39
 instrument tie
(cont’d)

This maneuver is accomplished by first grasping the fixed suture end with the
small and ring fingers, while it is being pinched between the tips of the index
finger and thumb. By pronating the wrist, a loop forms around the grasped
fingers, and the top of the loop must again be grasped between the tips of the
thumb and index fingers. The small and ring fingers are then withdrawn from
the loop before coiling more suture. The rasped suture can be easily lengthened
by releasing the coils held between the tips of the thumb and index finger.
When tying knots with an instrument, it is difficult to apply continuous
tension to the suture ends. Consequently, widening of the suture loop due to
slippage is frequently encountered in wounds subjected to strong tension. This
technique, however, is ideally suited for closing a wound which is subjected to
weak tensions. In this circumstance, instrument ties can be accomplished more
rapidly and accurately than hand ties, while conserving considerably more
suture. By using this technique, the parsimonious surgeon can complete 10
interrupted suture loops from one suture measuring 18 inches in length. This
feat would be impossible if the knots had been tied by hand.
The value of instrument ties has become readily apparent in special situations
in which hand ties are impractical or impossible. In microsurgical procedures,
an instrument tie provides the most reliable and easiest method of knot
construction. When employing suture in the recesses of the body (e.g. mouth,
vagina, etc.) or during endoscopic surgery, instruments can also form knots in
sites to which the hand could never gain access.
40
Hand tying of knots can be accomplished by either the two-hand or one-hand
technique. Each technique has distinct advantages as well as drawbacks. The two-hand
hand tie
technique of knot tying is easier to learn than the one hand. An additional advantage
of the two-hand tie is that the surgeon can apply continuous tension to the suture
ends until a secure knot is formed. With the one-hand method, it is often difficult to
maintain tension on the suture ends during the formation of the knot and slippage
of the first or second throws will be encountered, especially by the inexperienced
surgeon. When the surgeon attempts to shorten the resultant enlarged loop by
advancing the knot, breakage of the suture may occur, requiring passage of another
suture through the once punctured tissue. The student of surgery should master first
the construction of square type knots because knot security can usually be achieved
with fewer throws than the granny-type knots.21 The additional foreign bodies
required to form a secure granny knot, predisposes the wound to the development
of infection.
The hand-tying techniques illustrated in this manual are those used by right-handed
individuals. Using the two-hand technique, he/she constructs the knot predominantly
with his/her left hand, which forms a suture loop through which the free suture end
is passed. The left hand continually holds the suture end until knot construction
is complete. In contrast, the right hand merely holds, lets go, and regrasps the free
suture end. If the surgeon inadvertently manipulates the fixed suture end with his/her
right hand, he/she will be passing either the needle or reel through the formed loop.
The latter case is an invitation to needle puncture.
Many right-handed surgeons prefer to manipulate the free end of the suture with
their left and during two-hand ties. In such cases, the right hand performs the major
manipula-tion of the suture during formation of the loop. An advantage of this

41
 hand tie technique is that a surgeon who ties his/her own knots by
the two-hand technique during wound closure can hold the
(cont’d)
needle holder in his/her right hand during knot construction.
If one desired to learn to tie knots using the left hand to
manipulate the free end of the suture, study the illustrations
in a mirror.
Using the one-hand tie, one hand forms the suture loop while
manipulating the free suture end. The other hand merely
holds the mother suture end taut. Most surgeons prefer to
manipulate the free suture end with their left hand, allowing
them to hold the needle holder in their right hand while they
construct knots with their left hand.
There are several important recommendations for selecting a
knot tying technique. First, position the hands on each side of
and parallel to the suture loop. Second, grasp the appropriate
suture ends and form the suture loop, without exchanging
suture ends between the hands. While exchanging suture ends
between the hands forms a triangular-shaped suture loop, it
is an unnecessary step that wastes valuable time. Third pass
the free suture end, rather than the fixed suture end, through
the suture loop. Finally, reverse the position of the hands after

Figure 9. Standard format for illustrating

the knot tying technique.

42
each additional throw. Most of the knot tying techniques in this manual comply with these
recommendations. However, it is important to point out that the fixed end of the suture
is being passed through the suture loops in the two-hand ties. Consequently, the surgeon
must detach the needle from the fixed suture end before a two-hand tie.
A standard format for illustrating surgical knot tying techniques has been used throughout
the manual (Figure 9). A horizontal incision is pictured in the top of each illustration.
Because the wound edges are subjected to static tensions, there is retraction of the wound
edges, with exposure of the underlying tissue. The surgeon is standing facing the wound
from the bottom of each illustration. Because the surgeon usually passes the needle swaged
to a suture toward himself (herself), the fixed end (black) of the suture with its attached
needle enters the farther side of the mid-portion of the wound and exits from the side of
the wound closer to the surgeon. The free end of the suture is white to facilitate illustration
of the knot tying technique. The suture end (white) farther from the surgeon is grasped
between the tips of the distal phalanges of the left thumb and index finger (tip-to-tip
pinch). The tips of the distal phalanges of the thumb and index finger of the right hand
grasp the suture end (black) exiting from the wound edge closer to the surgeon. The
grasped fingers apply constant tension to the suture ends. The security of this tip-to-tip
pinch can be enhanced by grasping the suture ends between the tips of the long fingers,
ring fingers, small fingers, and the palm of each hand (grip activity).
The tying of square, slip, and surgeon’s knots using manual and instrument-tying
techniques are illustrated in Sections VIII-X. The technique of tying slip knots has been
included in the manual because it is an excellent method to approximate temporarily the
edges of wounds subjected to strong tensions In fact, a slip knot has greater holding power
than either a single-wrap or double-wrap throw.22 Once there is meticulous approximation
of wound edges, the slip knot can be converted to a square knot, after which a sufficient
number of throws are added to the knot to ensure knot security.
43
 VII. essential elements
DO
1. Pass the surgical needle swaged to a
suture through the wound edges in a
direction toward you.
2. Construct a two-throw square knot that
can be advanced to the wound edge,
providing a preview of the ultimate
apposition of the wound edges.
3. Approximate the edges of the divided
tissue without strangulating the tissue
encircled by the suture loop.
4. Once meticulous apposition of the
wound edges is achieved, construct a
knot that has has sufficient number of
throws that allow it to fail by breakage
rather than by slippage.
5. Position your hands on each side and
parallel to the suture loop.
44
DON’T
1. Pass the surgical needle swaged to a
suture through the wound edge in a
direction away from you.
2. Construct a secure knot that cannot be
advanced to the wound edges.
3. Apply frictional forces (sawing)
between the suture “ears” during knot
construction that damage the suture and
reduce its strength.
4. Add further throws to a knot that has
the required number of throws for
knot security.
5. Position your hands perpendicular to
the suture loop.
DO
6. Apply opposing forces to the knot
“ears” that are equal in magnitude
and in a plane parallel to that of the
wound surface.
7. After each throw, reverse the position of
your hands that apply tension to the
suture ends.
8. Apply constant force slowly to the
“ears” of each throw of the knot.
9. Use the two-hand tie technique to
maintain continuous tension on suture
ends.
10. During an instrument tie, position the
needle holder parallel to the wound.
11. Position the needle holder above the
fixed suture end to form the first and
second suture throws of a square
(1=1) knot.
12. Clamp only the free end of the suture
during the instrument tie.
DON’T
6. Exert unequal levels of tension to the
suture ends that convert the knot into
a slip knot.
7. Maintain the same position of your
hands after each additional throw.
8. Apply a constant force rapidly to the
“ears” of each throw of the knot.
9. Use the one-hand tie technique to
maintain continuous tension of the
suture ends.
10. During an instrument tie, position the
needle holder perpendicular to the
wound.
11. Position the needle holder above the
fixed suture end to form the first
throw, and then below the fixed suture
end to form the second throw of the
square knot (1=1).
12. Clamp the suture loop with an instru-
ment because it will crush the suture,
reducing its strength.30-32
45
 VIII. two-hand tie techniques — SQUARE KNOT (1=1)
formation of the first throw

Step 1.
Hold Suture Ends
The suture end exiting from the side of
the wound farther from the surgeon is
grasped between the tips of the distal
phalanges of the left thumb and index
finger (tip-to-tip pinch), while the tips
of the distal phalanges of the right thumb
and index finger grasp the suture end
exiting from the closer side of the wound.
The grasped fingers apply constant
tension to the suture ends. The security
of this tip-to-tip pinch of the suture
ends can be enhanced by grasping the
suture ends between the tips of the long
fingers, ring fingers, small fingers and
the palm of each hand (grip activity).

46
 Step 3.
Pass Thumb
Up Through
the Suture
Loop
The tip of the left
thumb advances up
through the suture
loop, replacing the
tip of the left index
finger.

Step 2. Step 4.
Form the First Suture Loop Pass Free
The first loop is formed by the tip of the Suture End
left index finger that passes its suture end Over the
over the other suture end held by the right Suture Loop
hand. As the tip of the left index finger The free suture end,
passes its suture end over the suture end held by the right hand,
held by the right hand, the left thumb is passed over (arrow)
passes under (arrow) the suture end held the suture loop.
by the right hand.

47
 VIII. two-hand tie techniques — SQUARE KNOT (1=1)
formation of the first throw (cont’d)

Step 5.
Pass Free Suture End Down
Through the Suture Loop
to Form Single-Wrap Throw
After the suture end is grasped between
the tips of the left thumb and index finger,
the pinched suture end is passed downward
through the suture loop. The right hand
releases its free suture end so that it can
be passed down through the suture loop.
The free suture end is regrasped between
the tips of the right thumb and index finger
to withdraw (arrow) it through the suture
loop to form a single-wrap throw.

48
Step 6.
Advance First Single-Wrap
Throw to Wound Surface
With the suture ends grasped in the palms of
the surgeon’s hands, the tips of the index
fingers and thumbs position the suture ends
in a direction (arrows) perpendicular to that
of the wound. The surgeon applies constant
tension to the suture ends, which advances
the first single-wrap throw of the square knot
to the surface of the wound. Advancement of
the first throw is complete when the divided
skin edges of the mid-portion of the wound
are approximated.

49
 VIII. two-hand tie techniques — SQUARE KNOT (1=1)
formation of the second throw

Step 7.
Begin Formation
of the Second
Suture Loop
The dorsum of the tip of the left
thumb is passed under its suture end
in order to direct it beneath (arrow)
the other suture end that is held by
the right hand. During formation of
the second throw, constant tension
is applied to the suture ends to
maintain wound approximation.

50
 Step 9.
Pass Index Finger Down
Through the Suture Loop
After the tip of the left
index finger contacts the
tip of the left thumb (tip-
to-tip pinch), both are
advanced down (arrow)
through the suture loop
so that only the tip of the
left index finger remains
in the loop.

Step 8. Step 10.

Form the Second Suture Loop Pass Free Suture End
The left thumb advances its suture end beneath Under the Suture Loop
the other suture end to form a suture loop. The free suture end held
The tip of the left index finger passes down by the right hand is
(arrow) to touch the left thumb. passed under the suture
loop to be positioned
(arrow) between the tips
of the left index finger
and thumb.

51
 VIII. two-hand tie techniques — SQUARE KNOT (1=1)
formation of the second throw (cont’d)

Step 11.
Pass Free Suture End
Up Through the Suture
Loop to Form Second,
Single-Wrap Throw
The free suture end grasped between the
tips of the left thumb and index finger
is advanced upward through the suture
loop. The right hand releases its free suture
end to allow its passage through the suture
loop, after which it regrasps the free suture
end to withdraw (arrow) through the
suture loop.

52
Step 12.
Advance Square Knot (1=1)
to Wound Surface
The second throw is advanced and set against
the first throw by applying tension in a direction
(arrows) perpendicular to that of the wound.
Advancement of the second throw is complete
when the second throw contacts the first throw
to form a square (1=1) knot. Ideally, the surgeon
should be able to advance the two-throw, square
knot to allow meticulous approximation of the
wound edges. Once exact approximation of the
wound edges is accomplished, the surgeon will
construct a knot with a sufficient number of
throws and 3mm cut “ears” so that knot security
is determined by knot breakage, rather than by
slippage.3

53
 VIII. two-hand tie techniques — SURGEON’S KNOT SQUARE (2=1)
formation of the first, double-wrap throw

Step 1.
Hold Suture Ends
The suture end exiting from the side of
the wound farther from the surgeon is
grasped between the tips of the distal
phalanges of the left thumb and index
finger (tip-to-tip pinch), while the tips of
the distal phalanges of the right thumb and
index finger grasp the suture end exiting
from the closer side of the wound. The
grasped fingers apply constant tension
to the suture ends. The security of this
tip-to-tip pinch of the suture ends can
be enhanced by grasping the suture ends
between the tips of the long fingers, ring
fingers, small fingers and the palm of each
hand (grip activity).

54
 1. Introduction Step 3.
Pass Thumb
Up Through
the Suture
Loop
The tip of the left
thumb advances up
through the suture
loop, replacing the
tip of the left index
finger.

Step 2. Step 4.
Form the First Suture Loop Pass Free
The first suture loop is formed by the tip of the Suture End
left index finger that passes its suture end over the Over the
other suture end held by the right hand. As the Suture Loop
tip of the left index finger passes its suture end The free suture end,
over the suture end held by the right hand, the left held by the right hand,
thumb passes under (arrow) the suture end held is passed over (arrow)
by the right hand. the suture loop.

55
 VIII. two-hand tie techniques — SURGEON’S KNOT SQUARE (2=1)
formation of the first, double-wrap throw (cont’d)

Step 5.
Pass Free Suture End Down
Through the Suture Loop to
Form Single-Wrap Throw
After the free suture end is grasped
between the tips of the left thumb and
index finger, the pinched suture end is
passed downward through the suture loop.
The right hand releases its free suture
end so that it can be passed through the
loop. The tips of the right thumb and
index finger regrasp the free suture end
to withdraw (arrow) it through the suture
loop to form a single-wrap throw.

56
 Step 7.
Pass Left Thumb
Up Into the
Suture Loop
The left thumb passes
up (arrow) through the
suture loop, replacing
the left index finger in
preparation for the
formation of the
double-wrap first
throw.

Step 6. Step 8.
Maintain Suture Loop with Left Index Finger Pass Free Suture End
The rectangular configuration of the suture Over the Suture Loop
loop is maintained by keeping the tip of The free suture end
the index finger (arrow) in the suture loop. held by the right hand is
passed over (arrow) the
suture loop and grasped
between the tips of the
left thumb and index
finger.

57
 VIII. two-hand tie techniques — SURGEON’S KNOT SQUARE (2=1)
formation of the first, double-wrap throw (cont’d)

Step 9.
Pass Free Suture End
Down Through the
Suture Loop to Form
Double-Wrap,
First Throw
The free suture end grasped between the
tips of the left thumb and index finger
is passed down (arrow) through the
suture loop. The right hand releases its
suture end so that it can be withdrawn
through the suture loop. As the free suture
end passes through the loop, it is regrasped
by the right hand to withdraw it through
the suture loop.

58
Step 10.
Advance Double-Wrap, First Throw to
Wound Surface
With the suture ends grasped in the palms
of the surgeon’s hands, the tips of the index
fingers and thumbs position the suture ends
in a direction (arrows) perpendicular to that
of the wound. The surgeon applies constant
tension to the suture ends, which advances
the double-wrap, first throw of the surgeon’s
knot square to the surface of the wound.
Advancement of the first throw is complete
when the divided edges of the mid-portion of
the wound are approximated.

59
 VIII. two-hand tie techniques — SURGEON’S KNOT SQUARE (2=1)
formation of the second throw

Step 11.
Begin Formation of the
Second Suture Loop
The dorsum of the tip of the left thumb
is passed under (arrow) its suture end
in order to direct it beneath the other
suture end that is held by the right
hand. During formation of the second
throw, constant tension is applied to
the suture ends to maintain wound
approximation.

60

Step 12.
Form the Second Suture Loop
The left thumb advances its suture end
beneath the other suture end to form
a suture loop. The tip of the left index
finger passes down (arrow) to touch
the left thumb.
Step 13.
Pass Index Finger Down
Through Suture Loop
After the tip of the left
index finger contacts the
tip of the left thumb (tip-
to-tip pinch), both are
advanced down (arrow)
through the suture loop so
that only the tip of the left
index finger remains in
the suture loop.
Step 14.
Pass Free Suture End
Under the Suture Loop
The free suture end held
by the right hand is passed
under the suture loop to
be positioned (arrow)
between the tips of the left
index finger and thumb.
61
 VIII. two-hand tie techniques — SURGEON’S KNOT SQUARE (2=1)
formation of the second throw (cont’d)

Step 15.
Pass Free Suture End Up
Through the Suture Loop
To Form Single-Wrap Throw
The free suture end grasped between the
tips of the left thumb and index finger is
advanced upward though the suture loop.
The right hand releases its free suture end
to allow its passage through the suture loop,
after which it regrasps the free suture end to
withdraw (arrow) it through the suture loop.

62
Step 16.
Advance Surgeon’s Knot
Square (2=1) to Wound Surface
The single-wrap throw is advanced and set against
the first double-wrap throw by applying tension
in a direction (arrows) perpendicular to that of
the wound. Advancement of the second throw
is complete when the second throw contacts
the first throw to form a surgeon’s knot square
(2=1). The direction of the tension applied to the
suture ends of the first throw is opposite to that
exerted on the suture ends of the second throw.
Once exact approximation of the wound edges is
accomplished, the surgeon will construct a knot
with a sufficient number of throws and 3mm cut
“ears” so that knot security is determined by knot
breakage, rather than by slippage.3

63
 VIII. two-hand tie techniques — SLIP KNOT (S=S)
formation of the first throw

Step 1.
Hold Suture Ends
The suture end exiting from the side of the
wound farther from the surgeon is grasped
between the tips of the distal phalanges
of the left thumb and index finger (tip-
to-tip pinch), while the tips of the distal
phalanges of the right thumb and index
finger grasp the suture end exiting from
the closer side of the wound. The grasped
fingers apply constant tension to the
suture ends. The security of this tip-to-tip
pinch of the suture ends can be enhanced
by grasping the suture ends between the
tips of the long fingers, ring fingers, small
fingers and the palm of each hand (grip
activity).

64
 Step 3.
Pass Thumb Up Through
the Suture Loop
The tip of the left thumb
advances up through the
suture loop, replacing the
tip of the left index finger.

Step 2. Step 4.
Form the First Suture Loop Pass Free Suture End Over
The first suture loop is formed by the tip of the Suture Loop
the left index finger that passes its suture end over The free suture end, held
the other suture end held by the right by the right hand, is passed
hand. As the tip of the left index finger passes over (arrow) the suture
its suture end over the suture end held by loop.
the right hand, the left thumb passes under
(arrow) the suture end held by the right hand.

65
 VIII. two-hand tie techniques — SLIP KNOT (S=S)
formation of the first throw (cont’d)

Step 5.
Pass Free Suture End Down Through the
Suture Loop
After the suture end is grasped between the
tips of the left thumb and index finger, the
pinched suture end is passed downward
through the suture loop. The right hand
releases its free suture end so that it can be
passed down through the suture loop. The
free suture end is regrasped between the
tips of the right thumb and index finger
to withdraw (arrow) it through the
suture loop.

66
Step 6.
Apply Tension to the Straight, Taut Suture End
The first throw of the slip knot is completed
by first applying tension (arrow) to the suture
held by the left hand causing the suture end
to be straight and taut. The suture end held
by the right hand forms a loop around the
straight, taut suture held by the left hand.
Step 7.
Advance First Throw
to Wound
The tip of the right index finger slides (arrow)
the loop along the straight, taut suture end held
by the left hand until the loop contacts the wound.
Advancement of the first throw is complete when
the divided skin edges of the mid-portion of the
wound are approximated.
67
 VIII. two-hand tie techniques — SLIP KNOT (S=S)
formation of the second throw

Step 8.
Begin Formation of
Second Suture Loop
The dorsum of the tip of the left thumb
is passed under its suture end in order
to direct it beneath (arrow) the other
suture end that is held by the right hand.
During formation of the second throw,
constant tension is applied to the suture
ends to maintain wound approximation.

68
 Step 10.
Pass Index Finger Down
Through the Suture Loop
After the tip of the left
index finger contacts the
tip of the left thumb (tip-
to-tip pinch), both are
advanced down (arrow)
through the suture loop
so that only the tip of the
left index finger remains
in the suture loop.

Step 9. Step 11.

Form the Second Suture Loop Pass Free Suture
The left thumb advances its suture end beneath End Under the
the other suture end to form a suture loop. Suture Loop
The tip of the left index finger passes down The free suture end held
(arrow) to touch the left thumb. by the right hand is passed
under the suture loop to
be positioned (arrow)
between the tips of the left
index finger and thumb.

69
 VIII. two-hand tie techniques — SLIP KNOT (S=S)
formation of the second throw (cont’d)

Step 12.
Pass Free Suture End Up Through
the Suture Loop
The free suture end grasped between
the tips of the left thumb and index
finger is advanced upward through the
suture loop. The right hand releases its
free suture end to allows its passage
through the suture loop, after which it
regrasps the free suture end to withdraw
(arrow) it through the suture loop.

70
Step 13.
Apply Tension to the Straight, Taut Suture End
to Form Second Throw
The tension applied (arrow) to the suture end
held by the left hand causes this suture end
to become straight and taut. The suture end
held by the right hand forms a second loop
around the straight, taut suture end held by
the left hand.
Step 14.
Advance Slip Knot (S=S) to Wound Surface
The tip of the right index finger slides (arrow)
this second throw against the first throw,
completing the slip knot (S=S), while the left
hand maintains tension (arrow) on its suture
end. The slip knot will become a square knot
by applying tension to the suture end held
by the right hand. (Insert) The square knot
can be converted to a slip knot by applying
tension primarily to one suture end.
71
 IX. one-hand tie technique — SQUARE KNOT (1=1)
formation of the first throw

Step 1.
Hold Suture Ends
The suture end exiting from the side of
the wound farther from the surgeon is
grasped between the tips of the distal
phalanges of the left thumb and index
finger (tip-to-tip pinch), while the tips
of the distal phalanges of the right thumb
and index finger grasp the suture end
exiting from the closer side of the wound.
The grasped fingers apply constant
tension to the suture ends. The security
of this tip-to-tip pinch of the suture ends
can be enhanced by grasping the suture
ends between the tips of the long fingers,
ring fingers, small fingers and the palm
of each hand (grip activity).

72
Step 2.
Form the First Suture Loop
The first throw of the square knot is initiated by
the tip of the left index finger that passes its free
suture end over the fixed suture end held between
the tips of the right index finger and thumb.
The tip of the left index finger begins to flex
around (arrow) the fixed suture end held by the
right hand. Note that the left hand forms the
suture loop and passes the free suture end through
the suture loop. Consequently, knot construction
can be safely accomplished without detaching
the needle from the fixed suture end.
Step 3.
Pass Index Finger Down into
The Suture Loop
As the index finger passes into the suture loop,
flexion of the tip of the left index finger
continues until the dorsal surface of its distal
phalanx contacts the free suture end held by the
left hand. After the free suture end rests on the
dorsal surface of the tip of the left index finger,
extension of the finger will begin withdrawal
(arrow) of the free suture end up through the
suture loop.
73
 IX. one-hand tie technique — SQUARE KNOT (1=1)
formation of the first throw (cont’d)

Step 4.
Begin Withdrawal of Free Suture End Up
Through the Suture Loop
Extension of the distal phalanx of the
left index finger brings the suture end
held by the left hand upward (arrow)
through the loop.

74
Step 5.
Pass Free Suture End Up Through
the Suture Loop
For the left index finger to bring the entire suture
end up (arrow) through the loop, the left hand
must release its grip of the suture. During this
interval, tension cannot be maintained continually
on the first throw, allowing the first-throw suture
loop to widen, with subsequent partial separation
of the wound edges.
Step 6.
Advance First Single-Wrap Throw
to Wound Surface
With the suture ends grasped in the palms of the
surgeon’s hands, the tips of the thumbs and index
fingers position the suture ends in a direction (arrows)
perpendicular to that of the wound. The surgeon
applies constant tension to the suture ends, which
advances the first, single-wrap throw of the square
knot to the surface of the wound. Advancement of
the first throw is complete when the divided skin edges
of the mid-portion of the wound are approximated.
75
 IX. one-hand tie technique — SQUARE KNOT (1=1)
formation of the second throw

Step 7.
Begin Formation of the
Second Suture Loop
While grasping the suture end
exiting from the farther side of the
wound between the tips of the left
thumb and index finger, the surgeon
supinates the left wrist so that the
free suture end is positioned over
the tips of the long, ring and
small fingers.

76
Step 8.
Form the Second Suture Loop
With continued supination of the wrist, the
tips of the left long and ring fingers advance
their free suture end under the suture end
held by the right hand to form a suture loop.
Step 9.
Flex Long Finger Toward the
Free Suture End
Continued flexion (arrow) of the distal phalanx
of the left long finger allows the tip of the finger
to pass beneath the free suture end held between
the tips of the left thumb and index finger.
77
 IX. one-hand tie technique — SQUARE KNOT (1=1)
formation of the second throw (cont’d)

Step 10.
Begin Withdrawal of the
Free Suture End Down Through
the Suture Loop
Once the dorsum of the distal phalanx of
the left long finger is beneath the free suture
end held between the tips of the left thumb
and index finger, extension of the distal
phalanx of the long finger begins to withdraw
(arrow) the suture end down through the
loop. For the left long finger to withdraw the
entire free suture end down through the
loop, the left thumb and index finger must
release their grip of the suture. During this
interval, tension cannot be maintained
continually on the first throw, allowing the
first-throw, suture loop to widen with subse-
quent partial separation of the wound edges.
78
Step 11.
Complete Withdrawal of the Free Suture End Down
Through the Suture Loop to Form Second,
Single-Wrap Throw
During withdrawal (arrow) of the free suture end through
the loop, it is held loosely between the tips of the left long
and ring fingers. This loose grasp (key pinch) between the
ulnar side of the distal phalanx of the left long finger and
the radial side of the distal phalanx of the left ring finger
does not allow constant tension to be maintained on this
suture end. For the left long and ring fingers to withdraw
(arrow) the entire suture end through the loop, the tips of
the left thumb and index finger must release the suture.
Step 12.
Advance Square Knot (1=1) to Wound Surface
The second throw is advanced and set against the first throw by
applying tension in a direction (arrows) perpendicular to that
of the wound. Advancement of the second throw is complete
when the second throw contacts the first throw to form a square
(1=1) knot. Ideally, the surgeon should be able to advance the
two-throw, square knot to allow meticulous approximation of the
wound edges. Once exact approximation of the wound edges is
accomplished, the surgeon will construct a knot with a sufficient
number of throws and 3mm cut “ears” so that knot security is
determined by knot breakage, rather than by slippage.3
79
 X. instrument-tie technique — SQUARE KNOT (1=1)
formation of the first throw (cont’d)

Step 1.
Position the Needle Holder
The instrument tie is performed with a
needle holder held in the surgeon’s right
hand.
The left hand holds the fixed suture end
between the tips of the thumb and index
finger. The needle holder is positioned
perpendicular to and above the fixed suture
end. By keeping the length of the free suture
end relatively short (<2 cm), it is easy to form
(arrow) suture loops as well as to save suture
material. Because the needle holder passes
the free suture end through the suture loop,
knot construction can be safely accomplished
without detaching the needle from the fixed
suture end.

80
Step 2.
Form the First Suture Loop
The fixed suture end held by the left hand
is wrapped over and around the needle
holder jaws to form the first suture loop.
(If the suture is wrapped twice around the
needle holder jaws, the first, double-wrap
throw of the surgeon’s knot square will be
formed. A double-wrap, first throw displays
a greater resistance to slippage than a single-
wrap throw, accounting for its frequent use
in instrument ties in wounds subjected to
strong, static skin tensions).

81
 X. instrument-tie technique — SQUARE KNOT (1=1)
formation of the first throw (cont’d)

Step 3.
Clamp Free Suture End
And Withdraw it Through
the Suture Loop to Form
the First, Single-Wrap
Throw
The tips of the needle holder jaws grasp
the suture end and withdraw (arrow) it
through the first suture loop. The resulting
first throw will have a figure “8” shape.

82
Step 4.
Advance the First Single-Wrap Throw to
Wound Surface
The figure “8” shape throw will be converted
into a rectangular-shaped throw by reversing
the direction of the hand movement. The left
hand moves away from the surgeon, while
the needle holder held in the right hand
advances toward the surgeon. This single-
wrap throw is advanced to the wound
surface by applying tension in a direction
(arrows) that is perpendicular to that of the
wound. Once the first throw of the square
knot contacts the skin, the edges of the
mid-portion of the wound are approximated.

83
 X. instrument-tie technique — SQUARE KNOT (1=1)
formation of the second throw

Step 5.
Position the Needle Holder
The needle holder releases the free suture
end. The right hand holding the needle
holder moves away from the surgeon to be
positioned perpendicular to and above the
fixed suture end. A second throw will be
formed by the left hand as it wraps the
fixed suture end over and around (arrow)
the needle holder jaws. If the surgeon were
to place the needle holder beneath the fixed
suture end, the ultimate knot construction
would be a granny knot (1x1).

84
Step 6.
Form the Second Suture Loop
The fixed suture end held by the left hand
is wrapped over and around the needle
holder to form the second suture loop.
With the suture wrapped around the needle
holder jaws, the needle holder is moved
to grasp the free suture end, after which
it is withdrawn through the suture loop.

85
 X. instrument-tie technique — SQUARE KNOT (1=1)
formation of the second throw (cont’d)

Step 7.
Clamp Suture End and Withdraw it Through
the Suture Loop to Form the Second,
Single-Wrap Throw
The tips of the needle holder jaws grasp
the free suture end and withdraw (arrow)
it through the second suture loop. By
withdrawing the free suture end through the
loop, a rectangular-shaped second throw is
formed. The surgeon will apply tension to the
suture ends in a direction perpendicular to
that of the wound.

86
Step 8.
Advance Square Knot (1=1)
to Wound Surface
The second throw is advanced and set against the
first throw by applying tension to the suture ends
in a direction (arrows) perpendicular to that of
the wound. Advancement of the second throw is
complete when the second throw contacts the first
throw and forms a square knot. Ideally, the surgeon
should be able to advance the two-throw, square
knot (1=1) to allow meticulous approximation of
the wound edges. Once exact approximation of
the wound edges is accomplished, the surgeon will
construct a knot using this instrument technique,
with a sufficient number of throws and 3mm cut
“ears” so that knot security is determined by knot
breakage, rather than by slippage.3

87
 XI. selection of suture and needle products

On the basis of the largest multicentric evaluation of suture and needle products
reported, suture and needle products made by Covidien (formerly Tyco
Healthcare Group LP, Norwalk, CT) received an extremely high acceptability
rating by the surgeons.33 In this multicentric evaluation of suture and needle
products conducted by Consorta, Inc. (Rolling Meadows, IL), 42 shareholder
hospitals enrolled 1913 surgeons to participate in this nonexperimental
observational study of the clinical performance of 25,545 suture and needle
products. Performance characteristics of the suture and needle products
produced by Covidien were judged by clinically acceptable and nonacceptable
ratings. Of these suture and needle products, the surgeons found that 98.1% had
clinical acceptable ratings for the 25,545 suture and needle products evaluated.
While the study coordinated by Consortia Inc. provides important guidelines
for judging the clinical acceptability of suture and needle products in a hospital
setting, this rigorous suture and needle performance evaluation confirms the
high level of performance of the suture and needle products made by Covidien.

88
 XII. full text scientific articles available
at www.covidien.com/syneture

A complete copy of this study can be found at www.covidien.com/syneture.

A. Rodeheaver GT, Shimer AL, Boyd LM, Drake DB, Edlich RF.
An innovative absorbable coating for the polybutester suture.
J Long Term Eff Med Implants 2001;11(1-2):41-54.

B. Szarmach RR, Livingston J, Rodeheaver GT, Thacker JG, Edlich RF.

An innovative surgical suture and needle evaluation and selection program.
J Long Term Eff Med Implants 2002;12(4):211-229.

C. Szarmach RR, Livingston J, Edlich RE. An expanded surgical suture and

needle evaluation and selection program by a healthcare resource management
group purchasing organization. J Long Term Eff Med Implants 2003;13(3):155-170.

D. Drake DB, Rodeheaver PE, Edlich RF, Rodeheaver GT. Experimental studies in
swine for measurement of suture extrusion. J Long Term Eff Med Implants
2004;14(3):251-259.

E. Pineros-Fernandez A, Drake DB, Rodeheaver PA, Moody DL, Edlich RF

Rodeheaver GT. Caprosyn™, another major advance in synthetic monofilament
absorbable suture. J Long Term Eff Med Implants 2005;14(5):359-368.
89
 XIII. references

1. Graumont R, Hensel J: Encyclopedia of knots and fancy rope work. Cornell

Maritime Press, N.Y., 1943, pp 3-10.
2. Haxton H: The influence of suture materials and methods on the healing
of abdominal wounds. Br J Surg 1965;52:372-375.
3. Thacker JG, Rodeheaver G, Kurtz L, Edgerton MT, Edlich RF. Mechanical
Performance of sutures in surgery Am J Surg 1977;133:713-715.
4. Trimbos JB. Security of various knots commonly used in surgical practice.
Obstet Gynecol 1984;64:274-280.
5. Edlich RF, Wind TC, Hill LG, Thacker JG, McGregor W. Reducing accidental injuries
during surgery. J Long Term Eff Implant 2003;13(1):1-10.
6. Edlich RF, Panek PH, Rodeheaver GT, Turnbull VG, Kurtz LD, Edgerton MT. Physical
and chemical configuration of sutures in the development of surgical infection.
Ann Surg 1973 Jun;177(6):679-688.
7. Postlethwait RW. Long-term comparative study of non-absorbable sutures.
Ann Surg 1970;171:892-898.
8. Rodeheaver GT, Nesbit WS, Edlich RF. Novafil, a dynamic suture for wound
closure. Ann Surg 1986;204:193-199.
9. Trimbos JB, Smeets M, Verdel M, Hermans J. Cosmetic result of lower midline
laparotomy wounds: polybutester and nylon skin suture in a randomized
clinical trial. Obstet Gynecol 1993;82(3):390-393.
90
10. Pinheiro AL, de Castro JF, Thiers FA, Cavalcanti ET, Rego TI, de Quevedo AS, Lins AJ,
Aca CR. Using Novafil: would it make suturing easier? Braz Dent J 1997;8(1):21-25.
11. Rodeheaver GT, Shimer AL, Boyd LM, Drake DB, Edlich RF. An innovative absorbable
coating for the polybutester suture. J Long Term Effects Med Implants 2001;11
(1 & 2):41-54.
12. Salthouse TN, Williams JA, Willigan DA. Relationship of cellular enzyme activity to catgut
and collagen suture absorption. Surg Gynecol Obstet 1981;129:691-696.
13. Rodeheaver GT, Thacker JG, Edlich RF. Mechanical performance of polyglycolic acid and
polyglactin 910 synthetic absorbable sutures. Surg Gynecol Obstet 1981;153:835-841.
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 Acknowledgements:
We would like to acknowledge the gifted talents of Graphic Designer,
Michael Lobasz, as well as the extremely talented pre-medical student,
Amy Cochran, the creative research assistant, Dayna Woode and the dynamic
Nursing Student, Jill Amanda Greene for all their innovative work
in getting this book completed.

This manual was illustrated by:

Craig A. Luce, MS.
Charlottesville, VA
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